Session-6 The DSM-5: Overview of Main Themes and Diagnostic Revisions

Question 1

When was the DSM-IV-TR first issued?

Answer 1

It was first issued in 1994, 968 pages long.

Question 2

When was the DSM-IV-TR first revised?

Answer 2

It was first revised in 2000, 988 pages long.

Question 3

When was the DSM-5 initiated?

Answer 3

Update initiated in 1999 and finally published on May 17, 2013, 947 pages long.

Question 4

What are the DSM-5 sections of the manual?

Answer 4

Section I: Introduction and information on how to use the manual.

Section II: Diagnostic criteria and codes

Section III: Emerging measures and models, conditions that require further research, a glossary, cultural concepts of distress, and names of persons involved in the manual’s development. (where all the new stuff they are adding is located).

Appendix.

Question 5

How was the DSM-5 developed?

Answer 5

APA organized groups of experts in distinct areas to assess diagnostic categories and disorders;

Came up with consensus viewpoints on symptomatic descriptors;

Field-tested new descriptors to determine revised diagnostic criteria (cluster sets and thresholds).

Presented to APA Board Trustees for sign-off

note: The development of it was political, the way they are supposed to be revised is that they are suppose to do more and more research, they look at patients and do all these analysis. But basically they end up in a room and a political process takes place, representatives from the pharmaceutical companies are connected to the final decision.

Question 6

What were the primary goals of DSM-5 Task Force in creating the new manual?

Answer 6

Increase cultural sensitivity;

Deepen the clinician’s understanding of the client;

Increase awareness of the neurobiology underpinning mental disorders;

Appraise the role of social and contextual factors associated with psychiatric symptoms.

note:
Neurobiology (bottom-up approach)
Case conceptualization- intra-psychic and contextual factors

Question 7

What was the first major change to DSM-5?

Answer 7

The multiaxial system has been abandoned.

Axes I, II, and III have been combined.

All clinical disorders are simply listed in order of priority (no real hierarchy of axes implied).

No more GAF (people tended to use very idiosyncratically, and did not follow the symptom severity x impairment rating codes)

Question 8

What was the second major change to DSM-5?

Answer 8

Incorporate a Spectrum Perspective (based on groupings that reside under the same family)

Question 9

DSM-5 change to Incorporate a Spectrum Perspective was based on what two emerging realizations?

Answer 9

Based on two emerging realizations in the field:

(1) There is not much evidence that disorders are actually categorically distinct from one another (both within and across diagnostic categories)
(2) The distinction between “normal” and “abnormal” behavior is ultimately, arbitrary.

Question 10

DSM-5 Incorporate a Spectrum Perspective; OCD was repositioned in what category?

Answer 10

Example: OCD is removed from the “Anxiety Disorders” category (DSM-IV-TR) and repositioned in a new category called “Obsessive-Compulsive and Related Disorders” (DSM-5).

The beam of light going into the prism (underlying core factor of anxiety) splits into several separate but related diagnostic categories.

Question 11

DSM-5 Incorporate a Spectrum Perspective; The 20 newly-refined diagnostic categories of mental disorders depict…?

Answer 11

updated groupings of all disorders, with each grouping sharing similar characteristics.

note:
Has resulted in a fair amount of reshuffling of the deck, e.g., “Neurodevelopmental Disorders” (includes Autism Spectrum Disorder, ADHD, and other disorders reflecting
abnormal brain development).

Question 12

What is the third major change to DSM-5?

Answer 12

Incorporate Dimensionality

Diagnostic thresholds (categorical/qualitative) are now supplemented by the degree to which the diagnosis is present (dimensional/quantitative).

Severity ratings (from minimal to more extreme levels): typically, symptom counts.

Question 13

What is the fourth major change to DSM-5?

Answer 13

Reflect a developmental perspective:

(1) Chapter structure of DSM-5 follows a neurodevelopmental life span approach (congruent with the system used by the ICD [World Health Organization]):

Early development: Neurodevelopmental Disorders; Schizophrenia Spectrum and Other Psychotic Disorders; etc.

Adolescence/early adulthood: Depressive Disorders; Anxiety Disorders; etc.

Later life: Neurocognitive Disorders.

note: The way dsm-5 is organized, in the beginning you have the early developmental..etc. they arranged it so that it is developmentaly congruent with the path of life.
(2) For specific disorders, variations of symptom presentations across the lifespan are described.

Question 14

What is the fifth major change to DSM-5?

Answer 14

Increase the emphasis on culture and gender.

Cultural information and gender differences are included wherever relevant.

Previous cultural formulation replaced with the Cultural Formulation Interview (CFI; pp. 750-757), a structured clinical interview that assesses the client’s subjective view of cultural factors re: the presentation of symptoms (effort is to diminish the clinician’s own cultural biases).

Question 15

What is the sixth major change to DSM-5?

Answer 15

Enhance Descriptive Information for Diagnoses:

Many specifiers provided.

Severity ratings provided.

Not Otherwise Specified (NOS) deleted, but here is what they came up with instead: if not meet full criteria for the disorder use “Other Specified” (need to give a reason) or “Unspecified Disorder” (don’t need to give a reason).

Question 16

What is the 7th major change to DSM-5?

Answer 16

Match the international classification of diseases (ICD) Codes

DSM-5 includes equivalent ICD-9 and ICD-10 codes.

The U.S. will adopt the ICD-10 in October, 2014; however, by that time, most of the world will already be using ICD-11.

note:
ICD codes is the medical world, most of DSM-5 matches ICD-10

Question 17

What is the 8th major change to DSM-5?

Answer 17

Reinvent DSM to be a “living” document:

DSM-5 (Arabic numeral) vs. DSM-IV-TR (Roman numeral).

More readily incorporate advances generated by new research, neuroscience, and investigations re: the genetics of psychiatric illness.

Question 18

What is the 9th major change to DSM-5?

Answer 18

Introduce the potential of the so-called “hybrid” model in subsequent DSMs

Question 19

Do Personality Disorders remain the same in DSM-5 as in DSM-IV-TR?

Answer 19

The Personality Disorders (PDs) essentially remain the same in DSM-5 as in DSM-IV-TR.

Question 20

Section III of DSM-5 introduces a hybrid…?

Answer 20

Introduces a hybrid (category and dimensional synthesized) model of PDs:

Level of impairment of personality functioning (dimensional) with ….

An evaluation of personality traits (categorical)

note: “whodaf”? Measures new measure like the GAF measure
Personality disorders have a combo of category and dimensionality. 4-TR based with category

Question 21

DSM-5: What are the five broad domains of personality traits?

Answer 21

(1) Negative Affectivity
(2) Detachment
(3) Antagonism
(4) Disinhibition
(5) Psychoticism

note: As a field, we are moving closer to defining what the core elements of psychiatric health/personality actually are

Question 22

What is the tenth major change to DSM-5?

Answer 22

Use biologically-based diagnostic criteria:

For some disorders, DSM-5 employs objective measures (genetic work-ups, neuroimaging, neurochemistry) into the criteria sets.

David Kupfer, M.D., the co-chair of the DSM-5 Task Force, indicated a keen interest in genetic tests/brain scanning/biomarkers/laboratory tests, but admitted that the field is not quite there yet.

note: He basically says the dSM-5 was disappointing, they wanted more diagnostic criteria to have more biologically based content in it, like blood tests and things and he is upset that a lot of it is still like psychological systems. He is saying I want 2929 to come now, this field wants to go towards scanning the fetus.

Question 23

DSM-5:

“Neurodevelopmental Disorders”

Answer 23

Intellectual Disabilities

Communication Disorders

Autism Spectrum Disorder

Attention-Deficit/Hyperactivity Disorder

Specific Learning Disorder

Motor Disorders

Other Neurodevelopmental Disorders

note: The title- diagnostic category, used to be called disorders usually first diagnosed in infancy, childhood and adolescence

Question 24

DSM-5: “Neurodevelopmental Disorders” : shifts

Separation Anxiety used to be in ____ now in____.

Answer 24

Separation Anxiety used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and is now in (DSM-5) “Anxiety Disorders”

Question 25

DSM-5: “Neurodevelopmental Disorders” : shifts

Selective Mutism used to be in ___ now in___.

Answer 25

Selective Mutism used to be in (DSM-IV-TR) “Disorders usually first diagnosed in Infancy, Childhood and Adolescence” and is now in (DSM-5) “Anxiety Disorders”

Question 26

DSM-5:

“Schizophrenia Spectrum and Other Psychotic Disorders”

Answer 26

Schizotypal (Personality)

Disorder

Delusional Disorder

Brief Psychotic Disorder

Schizophreniform Disorder

Schizophrenia

Schizoaffective Disorder

Substance/Medication-Induced

Psychotic Disorder

Psychotic Disorder Due to Another Medical Condition

Catatonia

Other/Unspecified

Question 27

DSM-5: “Schizophrenia Spectrum and Other Psychotic Disorders” Shifts

Schizotypal (Personality) Disorder used to be in _____ now in ____.

Answer 27

Schizotypal (Personality) Disorder used to be in (DSM-IV-TR) Axis II Personality Disorders and is now in (DSM-5) “Schizophrenia Spectrum and Other Psychotic Disorders” and “Personality Disorders”

Question 28

DSM-5: “Schizophrenia Spectrum and Other Psychotic Disorders” Shifts

Schizophrenia Disorder used to be in _____ now in ____.

Answer 28

Schizophrenia subtypes in (DSM-IV-TR) used to include “Paranoid, Disorganized, Catatonic, undifferentiated, and residual” and in (DSM-5) the subtypes are removed.

note: Inter-rater reliability was poor- you take 100 experienced clinicians give them the DSM-IV-TR and give them 1000 schizo patients the degree to which they say what subtype they are is very poor-either we don’t have the right descriptions or they are really poor, so they just eliminated them

Question 29

In the DSM-5 for “Schizophrenia Spectrum and Other Psychotic Disorders” is there greater emphasis on positive or negative symptoms?

Answer 29

DSM-5 minimizes importance of negative symptoms; emphasis is more on positive symptoms.

Question 30

DSM-5 for “Schizophrenia Spectrum and Other Psychotic Disorders” can now specify?

Answer 30

Can now specify severity (how many symptoms the person has): see dimensional rating scale “Clinician-Rated Dimensions of Psychosis Symptom Severity” in Section III of the DSM-5 Manual (pp. 742-744).

Question 31

DSM-5 “Schizophrenia Spectrum and Other Psychotic Disorders” diagnostic criteria must maintain..?

Answer 31

Delusions, hallucinations, disordered thinking (speech), and grossly disorganized or abnormal motor behavior (including catatonia) maintained.

Question 32

DSM-5:

“Bipolar and Related Disorders”

Answer 32

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disorder

Substance/Medication-Induced

Bipolar and Related Disorder

Bipolar and Related Disorder

Due to Another Medical Condition

Other and Unspecified

Question 33

DSM-5: “Bipolar and Related Disorders”: Shifts

Answer 33

Depressive Disorders and Bipolar Disorders no longer listed under the umbrella category of “Mood Disorders” (as was the case in DSM-IV-TR).

Question 34

DSM-5: “Bipolar and Related Disorders” note on primary criteria and specifier added?

Answer 34

The primary criteria for manic and hypomanic episodes now include an emphasis on changes in activity and energy as well as mood.

More specifiers added (p. 127):
e.g., “With anxious distress”: capture anxiety symptoms.

Question 35

DSM-5:

“Depressive Disorders”

Answer 35

Disruptive Mood

Dysregulation Disorder

Major Depressive Disorder

Persistent Depressive Disorder (Dysthymia)

Premenstrual Dysphoric Disorder (*new family member)

Substance/Medication-Induced

Depressive Disorder

Other and Unspecified

Question 36

DSM-5: “Depressive Disorders”: Shifts

Disruptive Mood Dysregulation Disorder

Premenstrual Dysphoric Disorder

Persistent Depressive Disorder (Dysthymia)

Bereavement

Answer 36

Disruptive Mood Dysregulation Disorder is new and now in (DSM-5) “Depressive Disorders”

Premenstrual Dysphoric Disorder used to be in (DSM-IV-TR) “Disorders in Need of Further Research” and now in (DSM-5) “Depressive Disorders”

Persistent Depressive Disorder (Dysthymia) used to be (DSM-IV-TR) “Dysthymic Disorder” in the “Depressive Disorders” subcategory of Mood Disorders and now in (DSM-5) “Depressive Disorders”

Bereavement used to be (DSM-IV-TR) V62.82 Major Depressive Disorder (MDD count not be diagnosed if symptoms were due to loss) and now in (DSM-5) MDD diagnosed even if symptoms are related to grief

Question 37

In DSM-5: How is an MDE with 3 manic symptoms coded?

Answer 37

A major depressive episode with at least 3 manic symptoms is now coded with the specifier “with mixed features”

Question 38

In DSM-5: What used to be known as “double depression”?

Answer 38

Persistent Depressive Disorder (Dysthymia): what used to be known as “double depression” (refractory major depressive episodes along with chronic sub-threshold depressive symptoms).

Question 39

DSM-5: What is a controversy with DMDD?

Answer 39

DMDD: Are we fostering the pathologizing of temper outbursts?

Question 40

DSM-5: What is a controversy with bereavement exclusion for MDD?

Answer 40

Removal of the bereavement exclusion for MDD: Are we over-pathologizing the normal bereavement process?

note: the threshold for getting disorders is getting lower and lower.

Question 41

DSM-5:

“Anxiety Disorders”

Answer 41

Separation Anxiety

Selective Mutism

Specific Phobia

Social Anxiety Disorder (Social Phobia)

Panic Disorder

Agoraphobia

Generalized Anxiety Disorder

Substance/Medication-Induced
Anxiety Disorder

Other and Unspecified

note: anxiety disorders use to be part of mood disorders

Question 42

DSM-5: “Anxiety Disorders”: Shifts

Separation Anxiety Disorder

Selective Mutism

Agoraphobia

OCD

Acute Stress Disorder

PTSD

Body Dysmorphic Disorder

Answer 42

Separation Anxiety Disorder used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and now in (DSM-5) “Anxiety Disorders”

Selective Mutism used to be in (DSM-IV-TR) “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence” and now in (DSM-5) “Anxiety Disorders”

Agoraphobia used to be in (DSM-IV-TR) “Panic Disorder without agoraphobia and agoraphobia with or without panic disorder in “Anxiety Disorders” and now in (DSM-5) “panic disorder and agoraphobia de-linked but still fall under “Anxiety Disorders”

OCD used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “Obsessive Compulsive and Related Disorders”

Acute Stress Disorder used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “Trauma and Stressor- Related Disorders”

PTSD used to be in (DSM-IV-TR) “Anxiety Disorders” and now in (DSM-5) “trauma and stressor- related disorders”

Body Dysmorphic Disorder used to be in (DSM-IV-TR) “somatoform disorders” and now in (DSM-5) “obsessive compulsive and related disorders”

Question 43

DSM-5:

GAD symptom duration was lowered from 6 to..?

Answer 43

Symptom duration lowered from 6 to 3 months

Question 44

DSM-5:

GAD associated symptoms of anxiety and worry lowered from 3 to..?

Answer 44

Associated symptoms of anxiety and worry lowered from 3 to 1 symptoms needed

note: Aaron Beck indicated this will result in a rise of “false positive” GAD diagnoses.

Question 45

DSM-5:

“Trauma- and Stressor- Related Disorders”

Answer 45

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

PTSD

Acute Stress Disorder

Adjustment Disorders

Other and Unspecified

Question 46

DSM-5: “Trauma- and Stressor- Related Disorders”: Shifts

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

PTSD

Acute Stress Disorder

Adjustment Disorders

Answer 46

Reactive Attachment Disorder used to be in (DSM-IV-TR) “Disorders usually first diagnosed in infancy, childhood, and adolescence” and now in (DSM-5) “trauma and stressor related disorders”

Disinhibited Social Engagement Disorder is a new disorder (DSM-5) in “trauma and stressor related disorders”

PTSD used to be in (DSM-IV-TR) “anxiety disorders” and now in (DSM-5) “trauma and stressor related disorders”

Acute Stress Disorder used to be in (DSM-IV-TR) “anxiety disorders” and now in (DSM-5) “trauma and stressor related disorders”

Adjustment Disorders used to be in (DSM-IV-TR) “adjustment disorders” and now in (DSM-5) “trauma and stressor related disorders”

Question 47

DSM-5: Are adjustment disorders a residual category?

Answer 47

Adjustment Disorders no longer a residual category (DSM-IV-TR subtypes retained)

Question 48

DSM-5: What two disorders are the result of a social neglect or other situation that limits a young child’s opportunity to form selective attachments?

Answer 48

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder (resembles ADHD)

Question 49

DSM-5: PTSD note?

Answer 49

For PTSD, attempted to specify “trauma” as an actual or threatened death, serious injury or sexual violation

Question 50

DSM-5: What controversy on “trauma and stressor related disorders”?

Answer 50

New criteria (i.e., “Emotional reactions to the traumatic event [fear, helplessness, horror]” [p. 274] no longer being necessary) may dilute what is actually deemed “traumatic.”

Diagnosis may occur for people who have not had direct exposure but merely learned about a violent traumatic event suffered by a loved one

Question 51

DSM-5:

“Substance Related and Addictive Disorders”

Answer 51

Substance Use Disorders

Alcohol-Related Disorders

Caffeine-Related Disorders

Cannabis-Related Disorders

Hallucinogen-Related Disorders

Inhalant-Related Disorders

Opioid-Related Disorders
Sedative-, Hypnotic-, and Anxiolytic-Related Disorders

Stimulant-Related Disorders

Tobacco-Related Disorders

Non-Substance-Related

Disorders (Gambling Disorder)

Question 52

DSM-5: What changes were made to “substance related and addictive disorders”?

Answer 52

“Abuse” and “dependence” have been collapsed into a single diagnostic category (addictions exist on a continuum: the spectrum perspective).

Severity of diagnoses (dimensionality) rated as mild, moderate, or severe, based on the number of symptoms.

note:

Love addiction, pornography, and sex addiction are now known as process addictions.

“First-time substance abusers are now lumped together with heroine addicts” (Zur Institute);
Category has been expanded beyond psychoactive substances (controversy)

Question 53

DSM-5:

“Neurocognitive Disorders”

Answer 53

Delirium

Major Neurocognitive Disorder (with Etiological Subtypes) 
		Alzheimer’s Disease
		Vascular Disease
		Traumatic Brain Injury
		HIV Infections
		Parkinson’s Disease
		Huntington’s Disease
		Substance/Medication.

Mild Neurocognitive Disorder (specifiers correspond to the disease process to which the cognitive decline is due)

note:
Formerly categorized in the DSM-IV-TR under the diagnostic category “Delirium, Dementia, and Amnestic and Other Cognitive Disorders.”

(controversy): Mild Neurocognitive Disorder: Are we pathologizing natural aging processes?

What is the distinction between illness and average expected generative decline?

Question 54

What is the Section III of the DSM-5?

Answer 54

Emerging Measures and Models

note: This is the experimental section, in DSM-6 this information will make new entries. Let make up some measures that are cutting across different diagnostic disorders

1. Assessment measures
2. alternate DSM-5 Model for Personality Disorders (The hybrid Model)
3. Conditions for further study

Question 55

DSM-5: #1 What are Assessment Measures?

Answer 55

“Cross-cutting Symptom Measure”: Basically, instead of thinking about a diagnostic disorder they are coming up with these measures that assess problematic symptom disorders, forget if this kid has adhd, major depressive disorder, odd, forget that, lets just do a symptom assessment.  The bottom up approach, we really care about the symptoms they have.

“Clinician-Rated Dimensions of Psychosis Symptom Severity”

Question 56

DSM-5: #1 Emerging Measures and Models, what is replacing the GAF?

Answer 56

World Health Organization Disability Assessment Schedule 2.0 (WHODAS)

Understanding and communicating

Getting around

Self-care

Getting along with people

Life activities (household, work, or school)

Participation in society

Question 57

DSM-5: #3 What are the conditions for further study?

Answer 57

Attenuated Psychosis Syndrome

Depressive Episodes with Short-Duration Hypomania

Persistent Complex Bereavement Disorder

Internet Gaming Disorder

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure

Suicidal Behavior Disorder

Nonsuicidal Self-injury

Question 58

DSM-5: What are the five major controversies?

Answer 58

1. will we overdiagnose with the DSM-5?
2. Are DSM-5 Diagnoses Valid?
3. Was the Process of Development of the Manual Flawed?
4. Are the DSM-5 Diagnoses Irrelevant to the Cause and Treatment of Psychological Problems?
5. Is the DSM Experiencing an Identity Crisis?

Question 59

1. will we overdiagnose with the DSM-5?

Answer 59

The dimensional perspective has a risk of over-pathologizing (i.e., pathologize normal behavior and/or normalize pathologic symptoms); usually referred to as the “reduced threshold” problem.
May lead to stigma/mislabeling of those who would do better without a psychiatric diagnosis

Question 60

2. Are DSM-5 Diagnoses Valid?

Answer 60

Allen Frances: DSM-5 introduces new, invalid diagnoses and contends the DSM-5 Task Force is merely helping the drug companies

National Institute of Mental Health (NIMH) director Thomas Insel announced that it would no longer use DSM diagnoses in research projects due to the manual’s lack of validity.

He contends the manual should be used solely as a dictionary so that clinicians share the same descriptions of symptoms.

Research indicates that 2 clinicians agree on a diagnosis of major depression only 60 percent of the time (Zur Institute)

Question 61

3. Was the Process of Development of the Manual Flawed?

Answer 61

Development was shrouded in secrecy; changes were not empirically supported.
Were the work groups merely flying by seat of their pants?
DSM-5 diagnoses are based on a consensus about clusters of clinical symptoms, not on any objective laboratory measure (in medicine: symptoms rarely indicate the best choice of treatment)

Question 62

4. Are the DSM-5 Diagnoses Irrelevant to the Cause and Treatment of Psychological Problems?

Answer 62

Despite changes in the DSM-5, it remains “a topographical symptom map” (Zur Institute): does not capture causal pathways that give rise to and maintain illness.

Question 63

5. Is the DSM Experiencing an Identity Crisis?

Answer 63

It is not clear if the DSM-5 is a diagnostic tool, a treatment tool, a research tool, or some combination of all of these: Is the DSM a good example of Multiple Personality Disorder?

Different groups use the DSM too loosely or too rigidly (little pragmatic consensus); Traditionally it was in place to help clinicians diagnose and research, “The three phase of Eve”

Question 64

How, in What Ways, for What Patients, under What Therapeutic Conditions Does Diagnostic Nomenclature Help or Hinder?

Answer 64

Best diagnostic tool is psychotherapy!